Hello Ilene: I hear your "pain" and I hope I can help.
In 1997, I worked at a large rehab hospital. Seeing 2 patients/hr was normal and 3/hr was not that rare. Like everyone else, OT and PT, I was just trying to see patients without having any REAL and personally meaningful treatment. I was pretty unhappy with the type of therapy that I was providing and honestly, using pegs, cones, UE exercises, etc was my normal pattern of treatment. But, in 1998 that changed. I don't remember how I first heard of this book, but I obtained a copy of: "Enabling Occupation, An Occupational Therapy Perspective". I am serious when I say that this book changed my practice patterns in ways that I still follow today. The book offers a step-by-step approach to becoming an "Enabling Occupation" therapist. But, it's not easy! As you know, today's corporate healthcare makes individualized treatment very difficult. And, the very sad reality is that YOUR setting may not allow you to be an OCCUPATIONal therapist. I once was fired from a SNF because I refused to practice like a robot. In my opinion, occupation-based practice will NOT work in every healthcare setting. That's not to say that therapists working in a SNF can't move towards occupation-based practice, but it will not be easy. But, if you are committed, it can occur. Make a commitment to identify your patient's occupational needs/desires. And, if they have NO occupational goals and/or potential for improvement, don't see them for therapy. Part of the problem may be that you are seeing people for OT who don't need OT. Once you identify OT goals, figure out what is keeping patients from achieving their goals. And then, get to work on fixing these problems. In some ways occupation-based practice is super easy, but in other ways it's very difficult. Sometimes, the greatest challenge is identifying occupational therapy goals. For example, I spent almost 2 HOURS yesterday with a home health patient just trying to understand where they wanted to go with their life. This is extreme, but I firmly believe that getting accurate goals is *THE* foundation of occupation-based treatment. You may also find that occupation-based practice challenges your comfort zone is that PT is "threatened" by what your NEW therapy involves. I say this, because in my experience, patient's primary goals almost ALWAYS involve mobility. Patient's want/need to be able to stand and walk by themselves in order to go to the toilet, dress themselves, shower, etc. I found that ambulation became a major focus of my treatment and sometimes, OT's are not comfortable with this, and PT's fell that you are encroaching on them. Of course, PT doesn't "own" ambulation any more than OT owns self-care. So, this is a long response that hopefully give a little encouragement and some direction. My final suggestion is "get the book"! <smile> Ron -- Ron Carson MHS, OT www.OTnow.com ----- Original Message ----- From: [email protected] <[email protected]> Sent: Wednesday, February 18, 2009 To: [email protected] <[email protected]> Subj: [OTlist] Puposeful activity ocn> Hi Joan and thanks for your insight! May I ask what you would want ocn> an OT to work on with you though before ocn> you had sufficient range to fasten your bra behind your back, if ocn> increasing the range of motion or adapting the task (i.e fastening ocn> int he front) were not options you would want? ocn> IMO, when therapists resort to cones, etc, it is not because they ocn> are lazy, it is because they don't know what else to do, either ocn> because they only have experience in work settings where cones and ocn> pegs were used, or they are in a subactute setting where they are ocn> seeing multiple people at once. Of course that is not ideal, but it ocn> is reality. I for one would like to move into this more ideal realm ocn> and change the way I practice, but there is precious little ocn> practical "how to's" for doing this, especially in settings like ocn> mine, where there is no kitchen, ADL suite, etc, and it is ocn> impossible to see everyone one on one for ADL's. There is no course ocn> that I can find on taking OT back to the functional in today's ocn> money-driven practice settings, in fact I have never seen a ocn> shoulder course for OT that doesn't focus on increasing range and ocn> other medically-based PT-type interventions. Even here, many people ocn> say "do this" but very few say specifically HOW or offer any ocn> practical ideas for the therapists stuck in peg/cone world who want ocn> to be more functional but are up against a practice world that just ocn> wants numbers. If you or anyone can offer any practical advice, ocn> point to a book or course to help therapists work more functionally ocn> with patients (who often, in a nursing home setting, can't even ocn> come up with goals of their own or answer "nothing" or "watch TV" ocn> when asked what they would like to be able to resume doing) I would be most appreciative. ocn> Thanks, ocn> Ilene Rosenthal, OTR/L ocn> Message: 1 ocn> Date: Tue, 17 Feb 2009 11:30:40 -0700 ocn> From: "Joan Riches" <[email protected]> ocn> Subject: Re: [OTlist] purposeful activity ocn> To: <[email protected]> ocn> Message-ID: ocn> <!~!uenerkvcmdkaaqacaaaaaaaaaaaaaaaaabgaaaaaaaaaqpieeyoaqeeuzxp6qay++8kaaaaqaaaa8ulnq9shyumb39sehxogoqeaa...@telusplanet.net> ocn> Content-Type: text/plain; charset="US-ASCII" ocn> Greetings to all ocn> I couldn't resist this one. ocn> In my opinion (like Ron's) all activity has purpose for someone or ocn> something (witness the reproduction of plants) . The OT question re the ocn> activities we use as treatment interventions is: Does this activity have ocn> purpose and therefore meaning for this client in terms of their explicit ocn> and implicit occupational goals? ocn> I absolutely agree with Ron's goal formulation where the only goal is ocn> some form of OCCUPATIONAL performance. ocn> (In the presence of cognitive deficits this becomes a much more ocn> difficult question.) ocn> Below is my personal physical and OT/PT case example. ocn> I've been thinking about it a lot in my present situation and how it ocn> plays out. I am still after 14 months working on the stability of the ocn> hip that was pinned and the range and strength in the shoulder with a ocn> nondisplaced fracture. Although I am determined not to walk or run with ocn> the typical 'hip' gait or to limit my reach and ability with my arm I ocn> find it very difficult to persist in activities that are not useful and ocn> meaningful 'at the time'. Especially now that the physical limitations ocn> are only apparent when I'm challenged - trying to walk a distance across ocn> a large parking lot quickly to keep an appointment for instance or ocn> helping to unload plywood from the truck or screwing a light bulb into a ocn> ceiling fixture - it is easy to have 'life' push out the daily ocn> excercises. I am not of the generation the 'works out for the sake of'. ocn> I have a brilliant and understanding PT. He knows the 30 to 45 straight ocn> minutes a day will just not get done. He knows that I want to recover ocn> not adapt. So he knows what I need to do and collaborates with me to ocn> find ways to incorporate the movements into my regular activities such ocn> as mindfully using the stairs, varying pace, not using the railings to ocn> pull myself up etc. The stairs themselves cue me as do the top shelves ocn> in the kitchen where I store at least three things that I use for ocn> breakfast each morning. ocn> My morning routine now includes an exercise where I need a significant ocn> break between sets. So I do a set and then clean my teeth etc. thus ocn> being purposeful with the 'dead' time. There is an exercise for my ocn> shoulder for which I need help. This has been tacked on to my husband's ocn> regular morning care. I do his compression stockings and he does my ocn> shoulder. Bob checks my style and is available if I have questions but ocn> my next visit will be in eight weeks - down from six the last time - ocn> down from 3X/week when we started. ocn> I have no doubt at all that what Bob does for me is PT. His purpose is ocn> directed to foundation abilities and what else affects my occupational ocn> performance is not his concern. Over time he sees my delighted reporting ocn> of the things I can do as evidence that his treatment of the foundation ocn> skill is effective. I have a good team with a PT and an OT(me). ocn> My occupational goals include all the things that I need to walk or run, ocn> reach, carry or support including the effective use of my hands to be ocn> able to do - however measureable goals are demanded from us. So for the ocn> shoulder I have picked one daily activity - doing up my bra that is a ocn> measureable goal to monitor progress. (can now do effectively but with ocn> some discomfort). ocn> So PT goal - to increase shoulder range and strength to facilitate ocn> dressing. ocn> OT goal - to fasten bra with both hands behind the back without ocn> discomfort. This is a good fit and focus for me - what would work for ocn> someone else in a similar situation will depend on whether it is an ocn> important thing to be able to do. Many women adapt by doing it up in ocn> front and twisting it around. ocn> Conclusion ocn> Any deficit affects so much in present or future occupational ocn> performance that I think some of us shy away from limiting the reason ocn> for working on something to one goal. The progress in the physical ocn> foundational skill is so easy to measure but it leaves out all the other ocn> the factors that also affect occupational performance. ocn> Thanks for reading this far. It has been a joy to see all the new ocn> members coming on. I haven't been at all active on the list lately ocn> partly because to say everything I want to takes me so long to type. I ocn> would very much appreciate your comments and feedback. ocn> So many topics to wade into - the discussions are bearing great fruit, I ocn> think. ocn> Soft theory - so important. ocn> Blessings, Joan ocn> Joan Riches B.Sc.O.T., OT(C) ocn> Specialist in Cognitive Disability ocn> Riches Consulting ocn> High River, Alberta, Canada ocn> 403 652 7928 ocn> -----Original Message----- ocn> From: [email protected] [mailto:[email protected]] On ocn> -- ocn> Options? ocn> www.otnow.com/mailman/options/otlist_otnow.com ocn> Archive? ocn> www.mail-archive.com/[email protected] -- Options? www.otnow.com/mailman/options/otlist_otnow.com Archive? www.mail-archive.com/[email protected]
